Eligibility Rules

The eligibility requirements for the PTC Health Insurance Plans are established solely by the underwriting department at Highmark Blue Cross Blue Shield.

In general, in order to be eligible for the health insurance programs employees must be considered full time by company requirements and work a minimum of 30 hours per week.

The following individuals are ineligible for coverage:

• Part-time employees working less than 30 hours per week
• Contract employees
• Casual employees who work from time to time without a definite schedule
• Board members not employed by the company

The following individuals are eligible for dependent coverage:

Spouse or common-law

Spousal coverage will begin on the employee's effective date for employees who are already married. Coverage will begin on the first of the month following the marriage date for those who marry after enrolling in a Highmark program.

Recognition of common-law marriage is at the employer's discretion; the employer is responsible for determining if a couple meets the eligibility requirements for spousal coverage. Highmark recommends using the following questions as a guideline:

• Does the couple have a joint/mortgage or rental agreement/lease?
• Do they have a joint bank account?
• Do they present themselves to society as a married couple?

If the employer believes the couple meets these requirements, the common-law spouse can be enrolled for coverage.

DOMESTIC PARTNER

Eligibility for coverage is determined by Highmark's definition of domestic partner. According to Highmark, couples meeting one or more of the following descriptions are eligible for coverage.

• A partnership consisting of two partners, each of whom has registered with a domestic partner registry in effect in the municipality/governmental entity within which the domestic partner currently resides.
• A partnership consisting of two partners, who meet the definition of a domestic partner as defined by the state or local government where the individual currently resides.
• A partnership consisting of two partners who each satisfy all of the following guidelines. Each person in the relationship:
  • is unmarried, at least 18 years of age, resides with the other partner and intends to continue to reside with the other partner for an indefinite period of time;
  • is not related to the other partner by adoption or blood;
  • is the sole domestic partner of the other partner and has been a member of this domestic partnership for the last six (6) months; and
  • agrees to be jointly responsible for the basic living expenses and welfare of the other partner;
  • meets (or agrees to meet) the requirements of any applicable federal, state, or local laws or ordinances for domestic partnerships which are currently enacted, or which may be enacted in the future.

A domestic partner shall be considered for eligibility as long as proof of a domestic partnership exists with the employer. In addition, the children of a domestic partner shall be considered for eligibility as if they were the children of the employee as long as the domestic partnership exists. Furthermore, to be considered an eligible dependent, the domestic partner must demonstrate financial interdependence with the employer by submission of proof of (3) or more of the following.

• a domestic partner agreement or proof of registry with a domestic partner registry;
• a joint mortgage or lease;
• a designation of one of the partners as beneficiary in the other partner’s will;
• a durable property and health care powers of attorney;
• such other proof as is sufficient to establish economic interdependency under the circumstances of the particular case.

The employer is responsible for determining if a person is eligible for coverage as a domestic partner and for reporting such eligibility to Highmark Blue Cross Blue Shield. Highmark Blue Cross Blue Shield reserves the right to request, at any time, documentation relative to eligibility for coverage of a domestic partner.

There may be tax implications for employer sponsored plans. The Internal Revenue Service requires that the value of health benefit coverage for a domestic partner be reported as income for the employee. It is the employee’s responsibility to be aware of the tax implications. Individuals and employers should consult a tax or legal advisor concerning the tax implications of adding a domestic partner to their benefit plan.

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Children

The following children are eligible for coverage under the our programs.

• Unmarried children under 19 years of age, including biological children, stepchildren, children legally placed for adoption, and legally adopted children are eligible for coverage on the employee's effective date.


• Newborn children are added the first of the month following their date of birth. Claims incurred on the days between the date of birth and the effective date are covered under the mother's name.


• Unmarried children between the ages of 19 and 25 are eligible provided that they are full-time students in an accredited school, college, or university and are solely dependent upon the employee for support. These dependents are eligible while attending school as well as during summer breaks, as long as they intend to return to school the following term.


• Unmarried children over age 19 who are unable to support themselves due to a physical disability or mental retardation are eligible.

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This information is not intended for use without professional advice. While we have attempted to make this site as accurate as possible, it is only a summary. For more information, see our disclaimer.

Last updated on:  Thursday, November 04, 2004  Page: 

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